Dentists could work for corporations, with a family, with other dentists, or with other types of group practices. When dentists become associates at group practices, they may either be in the owner’s insurance network or not. To avoid fraud, group practices’ claims must differentiate between owners and associates.
Owner vs associate claims
These practices must classify the dentist, regardless of his or her insurance networks, who cared for the patient. Their claims must indicate not only the owner but also the associate dentist who treated the patient. Patients treated by an associate not in their insurance network will receive out-of-network benefits, regardless of whether the practice’s owner is in their network.
If the owner wants the associate to be in his or her network, the owner must address this in the associate/owner agreement. The insurance company may also sign different contracts with the owner and the associate due to changes in the dental benefits marketplace. This means the owner and the associate may have different fee schedules. According to the CDA, “When a practice hires an associate, the practice must contact each plan the practice wants the associate contracted with to determine how best to proceed. Plans will need to update their claims processing system and associate the treating dentist to the billing entity or corporation to prevent claim rejection.”
Avoiding fraud
The practice commits fraud when it does not correctly list the dentist who cared for the patient as in-network or out-of-network. In this event, clinics could receive a termination letter or notice from a plan as well as a request for a refund for the work that was incorrectly billed. Dental plans regularly conduct office and claim audits to verify that charting, billing, and coding are in alignment with the benefits paid on behalf of their enrollee. The practice should consistently review its accounts to ensure patient charts, billing records, claim submissions, and appointment schedules correctly reflect the provider who rendered treatment.
While group practices may appeal to some dentists, they must know which associate provided treatment. By doing so, they avoid committing fraud in their claims. If you are struggling with billing associate claims consider partnering with eAssist. Our Success Consultants consistently bill claims under the treating doctor and ensure your claims are billed correctly every time. To learn more schedule a free consultation.
